ID:

EPIDEMIOLOGIC QUESTIONNAIRE
FOODBORNE DISEASE OUTBREAK INTENSIVE INVESTIGATION

THIS PAGE IS FOR ADMINISTRATIVE PURPOSES ONLY
TURN TO PAGE 2 FOR INTERVIEW AND QUESTIONNAIRE

Each time an attempt is made to contact the respondent, write down the date, time, and results of the call in the table below.

Call

Date

Time

Notes

1st Try

      

2nd Try

      

3rd Try

      

4th Try

      

5th Try

      
 

CIRCLE ONE RESPONSE PRIOR TO HANDING IN QUESTIONNAIRE.

What is the status of the interview?

  1. Interview was completed
  2. Interview was not completed because:
    1. Respondent refused to participate
    2. Respondent has not returned messages
    3. Still no answer after five attempts
    4. Phone number is disconnected
    5. Correct phone number is not known
  1. Other (specify________________________)
 

On what date was the interview conducted?

___ ___ / ___ ___ / 2000

Month 

 Day  Year
Name of Person to be interviewed __________________ , _______________
Last First

Work Phone Number ( __ __ __ ) - __ __ __ - __ __ __ __

Home Phone Number ( __ __ __ ) - __ __ __ - __ __ __ __
CDI #____
 

SECTION A: INTRODUCTION AND SCREENING FOR ILLNESS


INTRODUCE SELF
 Hello, my name is __________ and I'm calling from the Communicable Disease Program at the Chicago Department of Health.

WHY CALLING
 We're following up on some cases of diarrheal illness that occurred in people who attended an EVENT A at PLACE X in Chicago on DATE Y.

INFORMATION NEEDED
 I would like to ask you for some information related to the meal at that event, and about any illness you may have had following the event.


USE OF 
INFORMATION

 This may take 20-30 minutes to complete, but the information you provide is essential to us finding out if there was something at the event that made people ill, and making sure that no other people are put at risk.

CONFIDENTIALITY
 The information you provide will be kept confidential.

1

Did you attend this event?
  1. Yes
  2. No Þ

1a

Did you eat or taste any food or drinks from this event?

  1. Yes GO TO QUESTION 3 BELOW
  2. No DETERMINE IF CONTACTS ATTENDED

2

Were there other people who went with you?
  1. Yes Þ
  2. No

2a

FOR OTHER ATTENDEES, SPECIFY:
Name  Relationship  Phone #
(if different)
1. ___________________ ___________ ___________
2. ___________________ ___________ ___________
3. ___________________ ___________ ___________
4. ___________________ ___________ ___________

READ: We would like to talk to each of these people about what they ate and if they became ill. May I begin by getting some information from you?

3

Did you experience any symptoms of illness at any time following the event?

  1. Yes GO TO NEXT PAGE (ILLNESS SECTION)

  2. No GO TO SECTION C (FOOD SECTION)
S E C T I O N B : I L L N E S S READ: I'd like you to take a moment and tell me about your illness.

1

What was the FIRST SYMPTOM you experienced?

Þ

____________________________
First symptom(s)

2

On what day and time did it BEGIN?

  
_________  ____ : ____ AM
PM
DAY  TIME
 

Did you have:

  

How would you describe it?

  

On what day and time did it begin?

  

How long did it last?

  

At its worst, what was the most:

3

DIARRHEA or LOOSE STOOLS?

  1. YES Þ

  2. NO

3a

1. Watery
2. Bloody
3. Mucoid
4. Looser than Normal
5. Other [SPECIFY] _____________________

3b

  
__________  ___ : ____ AM
PM
DAY  TIME

3c

_______ DAYS

3d

_____ STOOLS/24 Hrs.

4

VOMITING?

  1. YES Þ

  2. NO

4b
__________  ___ : ____ AM
PM
DAY  TIME

4c

_______ DAYS

4d

______ TIMES/24 Hrs.

5

FEVER?

  1. YES Þ

  2. NO

5b
__________  ___ : ____ AM
PM
DAY  TIME

5c

_______ DAYS

5d

______ DEGREES

[If temp. not measured, write N.M.]

6

NAUSEA?

  1. YES Þ
  2. NO

6a

  

1. Severe
2. Moderate
3. Mild
9. Don't know

  

7

ABDOMINAL CRAMPS?

  1. YES Þ
  2. NO

7a

   1. Severe
2. Moderate
3. Mild
9. Don't know

8

MUSCLE ACHES?

  1. YES Þ
  2. NO

8a

   1. Severe
2. Moderate
3. Mild
9. Don't know

9

Did you have ANY OTHER SYMPTOMS? Þ

  1. YES [SPECIFY]_____________________________
  2. NO

10

On what date did you feel that your health was back to normal?
______ / ______ [If health still not normal, write STILL.]

Date
 

Did you visit a:

  

Name and phone # of hospital and/or provider?

  

Did you stay overnight?

  

Were you given IV fluids?

11

HOSPITAL or E.R.?

  1. YES Þ
  2. NO

11a

  
Name  Phone #
_____________  ________

11b

1. YES [SPECIFY]

Date admitted Date discharged
_____ / _____ _____ / _____

2. NO

11c

  1. YES

  2. NO

12

DOCTOR'S OFFICE ?

  1. YES Þ
  2. NO

12a

 
Name  Phone #
_____________________  ________________

13

OTHER MEDICAL PROVIDER ?

  1. YES Þ
  2. NO

13a

 
Name  Phone #
_____________________  ________________

14

Did you submit any SPECIMENS?

  1. YES Þ
  2. NO

14a

Where and when did you submit the specimen(s)?

 

Doctor/Facility Specimen type(s) Collection date

_____________ ______________ _____ / _____

14b

What were the results?

____________________________

____________________________

15

Were you PRESCRIBED any medications?

  1. YES Þ
  2. NO

15a

What medications?

___________________________________________

16

How limited were your normal activities?

1. Very limited

2. Somewhat limited

3. Not limited at all

Þ

17

Did you stay home from work (or school)?

1. YES [SPECIFY # DAYS MISSED: _______ ]

2. NO

3. DOES NOT WORK OUTSIDE HOME

18

OBTAIN INFORMATION BELOW FOR HOUSEHOLD CONTACTS AND OTHER ILL INDIVIDUALS KNOWN TO RESPONDENT

Name, location, phone # necessary for SENSITIVE OCCUPATIONS ONLY

NAME

AGE

RELATIONSHIP

ADDRESS

WAS AT EVENT?

ILL OR WELL

ONSET DATE

OCCUPATION / SCHOOL / INSTITUTION

NAME OF OCCUPATION

NAME & LOCATION OF BUSINESS/SCHOOL

PHONE
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   

S E C T I O N C : F O O D  H I S T O R Y

A

What time did you arrive at the event?

______ : ______ AM
PM
TIME

B

Did you have anything to eat or drink while you were at the event?

1. Yes Þ

2. No

B1

What time did you eat?
______ : ______ AM
PM
TIME
READ: Now I'd like to ask you about the foods you ate at the event. I’ll ask you if you ate a particular food, and I'd like you tell me if you had even a very small amount of that food. For each of the foods you had, I'd like to have you estimate how much of it you had.
 

Did you eat or taste any:

 

How much did you have?
 

There were two appetizers

1

Appetizer: MINI PIZZA (toast slice w/ tomato & cheese)

    1. Yes Þ
    2. No
    9. Don't know

1a

1. One appetizer or less

2. More than one but less than five appetizers

3. Five or more appetizers

9. Don’t know

2

Appetizer: SPINACH ROLL (wrapped in tortilla w/cream cheese)

    1. Yes Þ
    2. No
    9. Don't know

2a

1. One roll or less

2. More than one but less than five rolls

3. Five or more rolls

9. Don’t know
 

There were two different kinds of pasta dishes

3

PENNE PASTA WITH MARINARA (served hot w/tomato, olive oil, garlic, onions, basil)

    1. Yes Þ
    2. No
    9. Don't know

3a

1. One bite or less

2. More than one bite but less than five forkfuls

3. Five or more forkfuls

9. Don’t know

4

PASTA SALAD (served cold w/pasta, zucchini, squash, carrots, broccoli, cauliflower)

    1. Yes Þ
    2. No
    9. Don't know

4a

1. One bite or less

2. More than one bite but less than five forkfuls

3. Five or more forkfuls

9. Don’t know
 

5

GRILLED CHICKEN KABAB (served on skewers)

    1. Yes Þ
    2. No
    9. Don't know

5a

1. One bite or less

2. More than one bite but less than one skewer

3. One whole skewer

4. More than one skewer

9. Don’t know

6

FLOUR TORTILLA

    1. Yes Þ
    2. No
    9. Don't know

6a

1. One tortilla or less

2. More than one but less than five tortillas

3. Five or more tortillas

9. Don’t know

7

FRENCH BREAD

    1. Yes Þ
    2. No
    9. Don't know

7a

1. Less than one slice

2. One whole slice

3. More than one slice

9. Don’t know
 

There was a fresh vegetable tray with three vegetables and dipping sauces

8

CELERY STALKS

    1. Yes Þ
    2. No
    9. Don't know

8a

1. One stalk or less

2. More than one but less than five stalks

3. Five or more stalks

9. Don’t know

9

CUCUMBER SLICES

    1. Yes Þ
    2. No
    9. Don't know

9a

1. One slice or less

2. More than one but less than five slices

3. Five or more slices

9. Don’t know

10

FRESH RED PEPPERS

    1. Yes Þ
    2. No
    9. Don't know

10a

1. One slice or less

2. More than one but less than five slices

3. Five or more slices

9. Don’t know
 

(There were 2 kinds of dipping sauces)

  

(Sauces were spooned onto plates)

11

RED-PEPPER SAUCE

    1. Yes Þ
    2. No
    9. Don't know

11a

1. One spoonful or less

2. More than one but less than five spoonfuls

3. Five or more spoonfuls

9. Don’t know

12

COCONUT-PEANUT SAUCE

    1. Yes Þ
    2. No
    9. Don't know

12a

1. One spoonful or less

2. More than one but less than five spoonfuls

3. Five or more spoonfuls

9. Don’t know

13

ARTICHOKES

    1. Yes Þ
    2. No
    9. Don't know

13a

1. One petal (piece)

2. More than one but less than five petals (pieces)

3. Five or more petals (pieces)

9. Don’t know

14

VINAGRETTE DIP-SAUCE (for artichokes)

    1. Yes Þ
    2. No
    9. Don't know

14a

1. One spoonful or less

2. More than one but less than five spoonfuls

3. Five or more spoonfuls

9. Don’t know

15

BLACK BEAN SALSA (with corn and tomatoes)

 

    1. Yes Þ
    2. No
    9. Don't know

15a

1. One bite or less

2. More than one but less than five bites

3. Five or more bites

9. Don’t know
 

There were several different fresh fruits

16

WATERMELON

    1. Yes Þ
    2. No
    9. Don't know

16a

1. One wedge or less

2. More than one but less than five wedges

3. Five or more wedges

9. Don’t know

17

CANTALOUPE

    1. Yes Þ
    2. No
    9. Don't know

17a

1. One wedge or less

2. More than one but less than five wedges

3. Five or more wedges

9. Don’t know

18

PINEAPPLE

    1. Yes Þ
    2. No
    9. Don't know

18a

1. One wedge or less

2. More than one but less than five wedges

3. Five or more wedges

9. Don’t know

19

HONEYDEW MELON

    1. Yes Þ
    2. No
    9. Don't know

19a

1. One wedge or less

2. More than one but less than five wedges

3. Five or more wedges

9. Don’t know
 

There were 3 kinds of cakes and two other desserts

20

STRAWBERRY CAKE (pink icing)

    1. Yes Þ
    2. No
    9. Don't know

20a

1. One bite or less

2. More than one bite but less than one slice

3. One whole slice

4. More than one slice

9. Don’t know

21

WHITE CAKE (white icing)

    1. Yes Þ
    2. No
    9. Don't know

21a

1. One bite or less

2. More than one bite but less than one slice

3. One whole slice

4. More than one slice

9. Don’t know

22

CARROT CAKE

    1. Yes Þ
    2. No
    9. Don't know

22a

1. One bite or less

2. More than one bite but less than one slice

3. One whole slice

4. More than one slice

9. Don’t know

23

CHOCOLATE BROWNIES

    1. Yes Þ
    2. No
    9. Don't know

23a

# OF BROWNIES? __________

24

CHOCOLATE MOUSSE

    1. Yes Þ
    2. No
    9. Don't know

24a

1. One spoonful or less

2. More than one but less than five spoonfuls

3. Five or more spoonfuls

9. Don’t know
 

[Some of the drinks that were available were strawberry lemonade, iced tea, hibiscus tea (cold), and mineral water.]

25

What did you have to drink?

Name of Drink # How served
(glass,can,bottle,etc.) 		Ice?
1. __________________  ____  _______________  _____
2. __________________  ____  _______________ _____
3. __________________  ____  _______________ _____
4. __________________  ____  _______________ _____

FOR EACH DRINK: WRITE DOWN THE NAME OF THE DRINK, THE NUMBER CONSUMED, HOW IT WAS SERVED (GLASS, CAN, BOTTLE), AND IF ICE WAS ALSO CONSUMED.

26

Did you eat or taste any foods that I haven't already mentioned, such as condiments, sauces, desserts, snacks, fruits, or garnishes?

Name of Food How served How much
1. ____________ _____________________ ____________
2. ____________ _____________________ ____________
3. ____________ _____________________ ____________
4. ____________ _____________________ ____________

ASK FOR:

NAMES OF FOODS, DESCRIPTIONS OF HOW SERVED, AND QUANTITY CONSUMED

27

Do you have any leftover foods from the event?

  1. Yes Þ

  2. No

27a

May an investigator come out to your home to pick up this food?

LOCATION: _________________________________________

DATES: _________________________________________

TIMES: _________________________________________

28

Do you know of anyone who ate foods from the event but did not attend (such as someone who ate leftovers at home)?

  1. Yes Þ

  2. No

28a

Contact information for these individuals:
Name  Phone # ILL?(Y/N)

S E C T I O N D : D E M O G R A P H I C S

READ: To finish, I'd like to ask you for some information on your medical history and demographics. (This is confidential.)

1

Are there any foods that cause you to have problems (allergy, intolerance)?

    1. Yes [SPECIFY FOOD/REACTION____________________________ ]
    2. No
    9. Don't know

2

At the time of the event, were you taking any of these kinds of treatments? [CIRCLE ALL TAKEN]
  1. Antibiotics
  2. Antacids
  3. Steroids
  4. Chemotherapy

Þ

2a

FOR ALL TREATMENTS, SPECIFY:

Name of Treatment Reason for taking Dose taken
________________  _____________  _________
________________  _____________  _________
________________  _____________  _________

3

Have you ever had any of these medical conditions? [CIRCLE ANY CONDITIONS REPORTED AND SPECIFY DETAILS]

Type of condition Year of diagnosis Currently receiving treatment?
1. Diabetes
2. Cancer  __________________  ____________________ ________________________ 
3. Peptic ulcer
4. Heart disease __________________  ____________________ ________________________ 
5. Liver or Kidney disease
6. Stomach surgery __________________  ____________________ ________________________ 
7. Organ transplant
8. Suppressed Immune System __________________  ____________________ ________________________ 
9. Chronic diarrhea

4
What is your AGE?

___ ___ Years

5

SEX

  1. Male
  2. Female Þ

5a

CURRENTLY PREGNANT?

  1. Yes
  2. No

6

RACIAL/ETHNIC BACKGROUND?
    1. African-American or Black
    2. Caucasian or White
    3. Hispanic or Latino
    4. Asian or Pacific Islander
    5. Native American or Alaskan
    6. Other (specify_________________)
    8. Refused
    9. Don’t know

7

OCCUPATION

_____________________________________________

IF SENSITIVE OCCUPATION Þ

7a

PLACE OF WORK

Name: __________________________________

Location: ________________________________